so we're first going to scan Sarah's neck and as I usually Advocate I look for the bracho plexus in the super clavicular fossa I find the subclavian artery and the nerves color mode okay here's the subclavian artery and the nerves are above it scan upwards into your neck B mode and the scaling muscles come into view anterior scaling on the right and the middle scaling on the left and the Brach Plex is between them following the nerves up to the framan you can see them disappear they're black and hypo aoic scanning up her spine I'm looking at the cervical framan and the nerves going into the framan and after above the level of C5 the posterior tubic is larger than the anterior tubic so that's one way to distinguish between C4 and C3 versus C5 and C6 C6 is chasser tubal which is is a larger tubic the largest actually of the anterior tubic so once again the posterior tubic is larger above C5 and that's more or less how we know we're around the level of C4 also the kateed Ary will bifurcate as you see here at the level of C4 or C3 in most patients also we see the sternal cladal mastoid and at this point we could do a deep cervical plexus block by Landing the needle on the posterior tubric and injecting which is good for surgeries such as kateed and arterectomy or we could do a superficial cervical plexus block which gets the transverse cervical nerves which is good for postsurgical pain syndromes of the neck or cervicalgia of the neck as well as the supraclavicular nerve which is ideal for rib for clavical fractures and the lro oipal nerve now in this location I tried to demonstrate on the patient before the accessory nerve is sometimes hard to find but it basically runs from the jugular Fram and out towards the sternomastoid and then laterally towards the trapezius as we go down the neck and here's a trapezius this large muscle on top here we see the kateed and at the level of C6 is Chast trle which is going to hopefully come into view in a second right there large anterior process anterior tubic of C6 the target for the Stell gangon would be behind the c artery on top of the longest coli muscle where you could either come laterally to medially or come medial to laterally through the thyroid and as I look at the thyroid here with the trachy behind it I don't see any major blood vessels but the superior and inferior thyroid artery may come into view as I raise and lower my probe trying to find it color mode so here's the vasculature and I'm searching for the thyroid vasculature here there is some blood more medial to the thyroid some blood flow and there we go we're seeing a blood vessel inside the thyroid at the top this is probably the superior thyroid AR so this would be an ideal location to this stellate gangan block if we were to go trans thyroid I normally use a 25 gauge 1 and 1/2 in Needle it's usually long enough to get to the posterior border of the cored artery beyond that anterior to the longest coli muscle B mode and the longest coli muscle is here lying on top of the cervical transverse process at the bottom of the screen okay here I believe I found the C7 nerve route because there's no real anterior tubic to it I'm going to identify the nerve in the center and make sure it's not a blood vessel color mode okay it's not but there is a blood vessel above it so caution I am a little low I'm just going to scan up Superior that's a vertebral artery and it's going to come posterior as I Ascend and disappear into the Bony Canal which we may be able to see it there we go okay so at the level of C6 the vertebral argory goes posterior into the foran as it descends so from posterior approach now I could identify the cervical facet joints they look like shingles on the house and they're identified the gaps in the bone years ago before I started doing erector spin plane blocks I was performing what I called cervical facet plane blocks which were basically the same thing Landing the needle on the bone underneath the musculature and letting the local anesthetic diffuse superiorly and inferiorly along this to alleviate neck pain cervicalgia facet orthopathy and it actually worked quite well now I typically do not do cervical facet injections unless I'm injecting them with PRP I typically will do is a liing or bupivicaine medial branch block and use that for Diagnostic purposes prior to PRP injection or radio frequency ablation or peripheral neurom modulation
